Insurance Policy CHUBB

INSURANCE POLICY CHUBB

Policy Summary

Policy Number:   Effective Date:   Expiration Date:

Applicant / Insured Information

Date of Birth (if individual):   Contact Phone:   Email:

Individual    Corporation    LLC    Other

Policy Details & Premium

Total Insured Value / Coverage Amount: $   Deductible: $   Annual Premium: $

Coverages (Select applicable coverages)

Property (Building and Contents)   Limit: $   Deductible: $

Commercial General Liability   Each Occurrence: $   Aggregate: $

Cyber / Data Breach Coverage   Limit: $   Sub-limit (Forensic/Notification): $

Business Interruption / Extra Expense   Limit: $   Waiting Period (Hours):

Exclusions

The policy does not cover loss or liability arising directly or indirectly from: war, nuclear hazard, intentional acts by the insured, wear and tear, inherent vice, pollution except where specifically endorsed, or fraudulent acts. Losses excluded under other specific endorsements are also excluded. Clauses in this section are subject to the application of endorsements and state-mandated provisions where applicable.

Endorsements and Special Conditions

Beneficiary Designation (If Applicable)

List primary beneficiaries for benefits payable under this policy (if applicable to the line of coverage selected).

Relationship:   Share Percentage:

Relationship:   Share Percentage:

Claims — Notice and Documentation

In the event of a loss or claim the insured must provide prompt written notice to the insurer or authorized agent, preserve damaged property where practical, provide proof of loss, cooperate with reasonable requests for documentation and allow inspection and appraisal. Failure to timely notify the insurer or to cooperate may prejudice coverage to the extent permitted by law.

Policy Conditions and Legal Provisions

Insuring Agreement: Subject to the terms, conditions, limitations and exclusions of this policy, the insurer will indemnify the insured for covered losses occurring during the policy period up to the applicable limits of liability set forth herein.

Conditions: The insured must pay premiums when due, cooperate in the investigation and defense of claims, provide truthful representations in the application and notify the insurer of material changes in risk. Misrepresentation or material non-disclosure may render coverage void to the extent permitted by law.

Subrogation: When the insurer pays a covered loss, the insurer is subrogated to the insured’s rights of recovery against any third party, subject to insured cooperation and any salvage or recovery procedures specified in this policy.

Cancellation / Nonrenewal: This policy may be cancelled or nonrenewed in accordance with the terms of the policy and governing law. Where notice is required by statute or regulation, notice will be provided in writing to the insured at the mailing address indicated in this policy.

Governing Law & Dispute Resolution: This policy shall be governed by the laws specified in the policy declarations or required by governing jurisdiction. Disputes may be subject to arbitration if an arbitration clause is applicable and enforceable under governing law.

Severability & Entire Agreement: If any provision of this policy is held invalid, the remaining provisions shall remain in full force. This policy, together with the application, endorsements and declarations, constitutes the entire agreement between the parties respecting the subject matter hereof.

Certification and Authorized Signature

By signing below the undersigned represents that the information provided in this application and policy is true and complete to the best of their knowledge. The undersigned authorizes the insurer to obtain and exchange underwriting information, including claims and loss history, as necessary to administer the policy. The signature below constitutes acceptance of the terms, conditions, exclusions and endorsements of this policy. The insured acknowledges that acceptance of this policy is conditioned upon payment of the initial premium as required by the insurer.

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